The relationship between person-centered care in nursing homes and COVID-19 infection, hospitalization, and mortality rates.

OBJECTIVES: This cohort study compared rates of COVID-19 infections, admissions/readmissions, and mortality among a statewide person-centered model known as PEAK and non-PEAK NHs. METHODS: Rates per 1000 resident days were derived for COVID-19 cases and admissions/readmissions, and per 100 positive cases for mortality. A log-rank test compared rates between PEAK (n = 109) and non-PEAK NHs (n = 112). RESULTS: Rates of COVID-19 cases, admission, and mortality were higher in non-PEAK compared to PEAK NHs. The median rates for all indicators had a zero value for all NHs, but in NHs above 90th percentiles, the non-PEAK case rate was 3.9 times more and the admission/readmission rate was 2.5 times more. CONCLUSIONS AND IMPLICATIONS: COVID-19 case, and mortality rates were lower in PEAK than non-PEAK NHs. Although PEAK and non-PEAK NHs may differ in other ways as well, person-centered care may be advantageous to promote infection control and improve outcomes.

Excess Mortality Among Assisted Living Residents With Dementia During the COVID-19 Pandemic.

OBJECTIVE: To evaluate whether assisted living (AL) residents with Alzheimer's disease and related dementias (ADRD) experienced a greater rate of excess all-cause mortality during the first several months of the COVID-19 pandemic compared to residents without ADRD, and to compare excess all-cause mortality rates in memory care vs general AL among residents with ADRD. DESIGN: Retrospective cohort study. SETTING AND PARTICIPANTS: Two cohorts of AL residents enrolled in Medicare Fee-For-Service who resided in 9-digit ZIP codes corresponding to US AL communities of ≥25 beds during calendar year 2019 or 2020. METHOD: By linking Medicare claims and Vital Statistics data, we examined the weekly excess all-cause mortality rate, comparing the rate from March 12, 2020, to December 31, 2020, to the rate from January 1, 2019, to March 11, 2020. We adjusted for demographics, chronic conditions, AL community size, and county fixed effects. RESULTS: Of the 286,350 residents in 2019 and the 273,601 in 2020 identified in these cohorts, approximately 31% had a diagnosis of ADRD. Among all AL residents, the excess weekly mortality rate in 2020 was 49.1 per 100,000 overall during the pandemic. Compared to residents without ADRD, residents with ADRD experienced 33.4 more excess deaths per 100,000 during the pandemic. Among residents with ADRD, those who resided in memory care communities did not experience a statistically significant different mortality rate than residents who lived in general AL. CONCLUSIONS AND IMPLICATIONS: AL residents with ADRD were more vulnerable to mortality during COVID-19 than residents without ADRD, a finding similar to those reported in other settings such as nursing homes. Additionally, the study provides important new information that residents with ADRD in memory care communities may not have been at differential risk of COVID-19 mortality when compared to residents with ADRD in general AL, despite prior research suggesting they have more advanced dementia.

Impact of COVID-19 on Structure and Function of Program of All-Inclusive Care for the Elderly (PACE) Sites in North Carolina.

OBJECTIVES: The novel coronavirus disease 2019 (COVID-19) deeply affected all forms of long-term care for older adults, highlighting infection control issues, provider and staff shortages, and other challenges. As a comparatively new, community-based long-term care option, the Program of All-Inclusive Care for the Elderly (PACE) faced unique challenges. This project investigated the impact of COVID-19 on operations in all PACE programs in one US state. DESIGN: Qualitative study. SETTING AND PARTICIPANTS: Structured interviews with administrators of all 12 PACE programs in North Carolina. METHODS: Interviews were conducted December 2020 to January 2021 by trained interviewers over Zoom; they were transcribed, coded, and qualitatively analyzed using thematic analysis. RESULTS: Reported COVID-19 infection rates among PACE participants for 2020 averaged 12.3 cases, 4.6 hospitalizations, and 1.9 deaths per 100 enrollees. Six themes emerged from analyses: new, unprecedented administrative challenges; insufficient access to and integration with other health care providers; reevaluation of the core PACE model, resulting in a transition to home-based care; reorientation to be more family-focused in care provision; implementation of new, creative strategies to address participant and family psychological and social well-being in the home; and major reconfiguration of staffing, including transitions to new and different roles and a concomitant effort to provide support and relief to staff. CONCLUSIONS AND IMPLICATIONS: While facing many challenges that required major changes in care provision, PACE was successful in mounting a COVID-19 response that upheld safety, promoted the physical and mental well-being of participants, and responded to the needs of family caregivers. Administrators felt that, after the pandemic, the PACE service model is likely to remain more home-based and less reliant on the day center than in the past. As a result, PACE may have changed for the better and be well-positioned to play an expanded role in our evolving long-term care system.

Dementia and COVID-19 infection control in assisted living in seven states.

BACKGROUND: Assisted living (AL) is the largest residential long-term care provider in the United States, including for persons with Alzheimer's disease and related dementias. Despite recognizing the challenge of infection control for persons with dementia, this study of 119 AL communities is the first to describe dementia-relevant COVID-19 infection control across different types of AL communities, and to discuss implications for the future. METHODS: From a parent study sampling frame of 244 AL communities across seven states, 119 administrators provided data about COVID-19 infection control practices and resident behaviors. Data were collected from July 2020 through September 2021. Communities were differentiated based on the presence of beds/units dedicated for persons living with dementia, as being either dementia-specific, mixed, or integrated. Data obtained from administrators related to feasibility of implementing seven infection control practices, and the extent to which residents themselves practiced infection prevention. Analyses compared practices across the three community types. RESULTS: Less than half of administrators found it feasible to close indoor common areas, all community types reported a challenge organizing group activities for safe distancing, and more than half of residents with dementia did not wear a face covering or maintain physical distance from other residents when indicated. Dementia-specific AL communities were generally the most challenged with infection control during COVID-19. CONCLUSION: All AL community types experienced infection control challenges, more so in dementia-specific communities (which generally provide care to persons with more advanced dementia and have fewer private beds). Results indicate a need to bolster infection prevention capacity when caring for this especially vulnerable population, and have implications for care in nursing homes as well.

Advancing Clinical Trials in Nursing Homes: A Proposed Roadmap to Success.

An effective clinical research effort in nursing homes to address prevention and treatment of COVID-19 faced overwhelming challenges. Under the Health Care Systems Research Network-Older Americans Independence Centers AGING Initiative, a multidisciplinary Stakeholder Advisory Panel was convened to develop recommendations to improve the capability of the clinical research enterprise in US nursing homes. The Panel considered the nursing home as a setting for clinical trials, reviewed the current state of clinical trials in nursing homes, and ultimately developed recommendations for the establishment of a nursing home clinical trials research network that would be centrally supported and administered. This report summarizes the Panel's recommendations, which were developed in alignment with the following core principles: build on available research infrastructure where appropriate; leverage existing productive partnerships of researchers with groups of nursing homes and nursing home corporations; encompass both efficacy and effectiveness clinical trials; be responsive to a broad range of stakeholders including nursing home residents and their care partners; be relevant to an expansive range of clinical and health care delivery research questions; be able to pivot as necessary to changing research priorities and circumstances; create a pathway for industry-sponsored research as appropriate; invest in strategies to increase diversity in study populations and the research workforce; and foster the development of the next generation of nursing home researchers.

COVID-19 Perspectives of Assisted Living and Health Care Providers in Seven States

Thirty percent of COVID-19 deaths in long-term care were in assisted living (AL), indicating challenges providing care. This project recruited AL administrators and medical and mental health care providers in a seven-state stratified random sample of 250 communities;it asked what was most challenging responding to COVID-19, what was successful, how to have better dealt with COVID-19, and how others could have helped. The most common challenge was addressing residents’ psychosocial needs, explained as “No contact - no hugging. The seniors require touch. It's something we've always done, and we can't do;we're required not to do it.” Successes included infection prevention, and in hindsight, administrators discussed staffing. Related to external entities, one commented, “Come in the building and see what we're doing. Don't sit behind a freaking screen and act like you know what we're doing.” Providers stressed patient access to care and social isolation. Implications will be discussed.

Nursing Homes and COVID-19: Staff Experiences

Nursing homes (NHs) faced an unprecedented crisis during the rapid spread of COVID-19. This pandemic has had a devastating impact on both NH residents and workers who are often on the frontlines providing hands-on care. These workers are vulnerable to the health risks of COVID-19 due to daily exposure to residents with COVID-19, residence in areas with high infection rates, and challenges specific to low-income workers (e.g. reliance on mass transportation). Research has highlighted the experiences of NH workers during the pandemic to learn how to better support them now and during future pandemics. This symposium will add to this research and present new findings from studies conducted in the United States to capture the unique experiences of NH employees. First, Bryant illustrates specific COVID-19-related challenges that NH frontline workers faced and how these workers’ experiences compare to workers in other long-term services and support settings. Reinhardt reports findings from a qualitative study examining the multi-level challenges experienced by nursing assistants during the pandemic. Cimarolli examines if quality of employer communication and workers’ perceived COVID-19-related preparedness mitigate the impact of work-related stress on NH workers’ decision to resign. Franzosa shares recommendations based on priorities identified by nursing assistants and administrators to build future resilience based on lessons learned. Finally, Simpson identifies factors associated with states’ decisions to adopt COVID-19 testing mandates for workers in NHs. Dr. Zimmerman discusses study findings and their contributions for creating supportive NH work environments to ensure most optimal NH worker and resident quality of life.

COVID-19 Response In U.S. Assisted Living Settings: Key Stakeholder Perspectives

Unique regulatory requirements and scope of services within assisted living (AL) pose distinctive challenges to COVID-19 response. To identify COVID-19 issues specific to AL, we recruited stakeholders with expertise in AL operations, policy, practice, and research (n=42) to participate in remote interviews between July and September 2020. Using thematic analysis, we derived the following overarching themes: 1) Policymakers lack an understanding of the AL context;2) AL administrators were left to coordinate guidelines with little support;3) AL organizations faced limited knowledge of and disparate access to resources;4) State-level regulatory requirements conflicted with COVID-19 guidelines resulting in confusion;and 5) AL operators struggled to balance public health priorities with promoting their residents’ wellbeing. To develop evidence-informed policy and avoid unintended consequences, AL operators, direct care workers, residents, and clinicians practicing in these settings should have opportunities to provide feedback through the policy development process, both state and national.

Seven-State Study of Assisted Living and Healthcare Providers’ Responses to COVID-19

COVID-19 has inordinately affected assisted living (AL), such that the proportion of fatalities to cases has been 21% in AL versus 2.5% for the general population. Understanding how AL administrators and medical and mental health providers have responded to COVID-19 can inform health care going forward. Using a seven-state stratified random sample of 250 communities, administrators were interviewed and providers completed questionnaires regarding COVID-19 practices. Preliminary data indicate that 79%, 44%, and 62% of administrators reported serving meals in rooms to segregate residents, using telemedicine, and providing extra pay for staff, respectively. Perceived use/effectiveness of practices differed based on dementia case-mix (e.g., face coverings, social distancing). Providers reported less access to patients (82%), more telehealth (63%), and less ability to provide care (43%). However, they uniformly reported high confidence in AL staff ability to prevent (94%) and respond to outbreaks (96%). Discussion will summarize points important for future care.

Excess Mortality Attributable to COVID-19 Among Assisted Living Residents

This study examines the excess mortality attributable to COVID-19 among a national cohort of assisted living (AL) residents. To do this, we compare the weekly rate of all-cause mortality during 1/1/20-8/11/20 with the same weeks in 2019 and calculated adjusted incidence rate ratios (IRRs) and 95% confidence intervals (CIs). All-cause mortality rates, nationally, were 14% higher in 2020 compared with 2019 (mean, 2.309 vs. 2.020, respectively, per 1000 residents per week;adjusted IRR, 1.169;95% CI 1.165-1.173). Among the 10 states with the highest community spread, the excess mortality attributable to COVID-19 was 24% higher, with 2.388 deaths per 1000 residents per week in 2020 during January-August vs 1.928 in 2019 (adjusted IRR, 1.241;95% CI 1.233-1.250). These results suggest that AL residents suffered excess mortality due to COVID-19.

Certified nursing assistants' experiences with self-compassion training in the nursing home setting.

Certified nursing assistants (CNAs) in nursing home (NH) settings experience considerable work-related and personal stress. Self-compassion is a personal resource linked to improved stress coping and may be particularly relevant to health care workers. In this study, we explored NH CNA's experiences with self-compassion training based on their narrative replies. Twenty-two CNAs (100% female, mean age 48 years, 82% Black/African American) from 3 mid-sized, non-profit NHs in the Southeast US completed either a standard 8-week, 20 h self-compassion training or a 6-week, 6 h modified version designed for health care providers. Qualitative data analyses from post-training focus group discussions identified four themes pertaining to changes in: (1) stress management, (2) appreciation and support, (3) caregiver role, and (4) connection to others. Findings suggested self-compassion training is feasible and beneficial for the stressors that CNAs experience. In the era of COVID-19 and beyond, self-compassion training is a promising method to improve CNAs' well-being.

Coronavirus Disease 2019 Regulatory Response in United States-Assisted Living Communities: Lessons Learned.

Coronavirus disease 2019 (COVID-19) has disproportionately affected residents, their families, staff, and operators of congregate care settings. Assisted living (AL) is a type of long-term care setting for older adults who need supportive care but not ongoing nursing care and emphasizes a social model of care provision. Because AL is a type of long-term care, it has at times been referenced along with nursing homes in discussions related to COVID-19 but not recognized for its different care practices that pose unique challenges related to COVID-19; in that manner, it has largely been left out of the COVID-19 discourse, although ~812,000 older adults live in AL. To identify COVID-19 issues specific to AL, stakeholders with expertise in AL operations, policy, practice, and research (n = 42) were recruited to participate in remote interviews between July and September 2020. Using a thematic analysis, we derived the following overarching themes: (1) Policymakers are disconnected from and lack an understanding of the AL context; (2) AL administrators were left to coordinate, communicate, and implement constantly changing guidelines with little support; (3) AL organizations faced limited knowledge of and disparate access to funding and resources; (4) state-level regulatory requirements conflicted with COVID-19 guidelines resulting in uncertainty about which rules to follow; and (5) AL operators struggled to balance public health priorities with promoting their residents' quality of life and well-being. To develop evidence-informed policy and avoid unintended consequences, AL operators, direct care workers, residents, and clinicians practicing in these settings should have opportunities to provide feedback throughout the policy development process, both state and national.

Addressing Systemic Racism in Nursing Homes: A Time for Action.

Long-term services and supports for older persons in the United States are provided in a complex, racially segregated system, with striking racial disparities in access, process, and outcomes of care for residents, which have been magnified during the Coronavirus Disease 2019 pandemic. These disparities are in large measure the result of longstanding patterns of structural, interpersonal, and cultural racism in US society, which in aggregate represent an underpinning of systemic racism that permeates the long-term care system's organization, administration, regulations, and human services. Mechanisms underlying the role of systemic racism in producing the observed disparities are numerous. Long-term care is fundamentally tied to geography, thereby reflecting disparities associated with residential segregation. Additional foundational drivers include a fragmented payment system that advantages persons with financial resources, and reimbursement policies that systematically undervalue long-term care workers. Eliminating disparities in health outcomes in these settings will therefore require a comprehensive approach to eliminating the role of systemic racism in promoting racial disparities.

COVID-19 Recommendations for Assisted Living: Implications for the Future.

OBJECTIVES: Assisted living (AL) emerged over 2 decades ago as a preferred residential care option for older adults who require supportive care; however, as resident acuity increased, concern has been expressed whether AL sufficiently addresses health care needs. COVID-19 amplified those concerns, and an examination of recommendations to manage COVID-19 may shed light on the future of AL. This review summarizes recommendations from 6 key organizations related to preparation for and response to COVID-19 in AL in relation to resident health and quality of life; compares recommendations for AL with those for nursing homes (NHs); and assesses implications for the future of AL. DESIGN: Nonsystematic review involving search of gray literature. SETTING AND PARTICIPANTS: Recommendations from key governmental bodies and professional societies regarding COVID-19 in AL, long-term care facilities (LTCFs) in general, and NHs. MEASURES: We collected, categorized, and summarized these recommendations as they pertained to quality of life and health care. RESULTS: Many recommendations for AL and NHs were similar, but differences provided insight into ways the pandemic was recognized and challenged AL communities in particular: recommending more flexible visitation and group activities for AL, providing screening by AL staff or an outside provider, and suggesting that AL staff access resources to facilitate advance care planning discussions. Recommendations were that AL integrate health care into offered services, including working with consulting clinicians who know both the residents and the LTC community. CONCLUSIONS AND IMPLICATIONS: Long-term care providers and policy makers have recognized the need to modify current long-term care options. Because COVID-19 recommendations suggest AL communities would benefit from the services and expertise of social workers, licensed nurses, and physicians, it may accelerate the integration and closer coordination of psychosocial and medical care into AL. Future research should investigate different models of integrated, interdisciplinary health care in AL.